TransMedicare
Healthcare Advocacy for the Transgender Community

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Medicare and its Parts

Medicare Part A
In general, Part A covers: 
Hospital care
Skilled nursing facility care
Nursing home care (as long as custodial care isn't the only care you need)
Hospice
Home health services

Medicare Part B
Part B pays for a portion of your doctor visits, some home health care, medical equipment, outpatient procedures, rehabilitation therapy, laboratory tests, X-rays, mental health services, ambulance services and blood. The portion is generally 80% of the Medicare contractual amount (which is not what a cash payment amount would be if directly paying the surgeon. Medicare has low reimbursement rates and that is why many surgeons won't accept it for costly transgender procedures).

**Part B is optional, and you may want to opt out of Part B if you still have health insurance through an employer, union, your spouse, etc. Part B requires that you pay a monthly premium to Medicare. . 

Part C   Advantage plans combine parts A, B, and your Part D drug plan.  They operate at local levels to provide services and have providers and hospitals contracted to their insurance plans. Medicaid plans (low income insured who are duel eligible) will run like Advantage plans.  There is a lot of confusion on how the Medicaid plans will reimburse in states that have no specific coverage.  

Part D is a drug plan that you select or is selected for you by a Medicaid plan when they pay your premiums. You can use the Medicare . gov page to find drug plans in your area.

Other Parts of Medicare
GAP Plans- Cover the portion of the medical bill that is not covered by Original Medicare.  There are several options available depending on the amount of copayment you are willing to take on.  Typically full coverage is averaging around $150 a month for me over the last 5 years.

A warning about delayed enrollment: If you opt out of Part B when you initially enroll in Medicare but later decide that you want the coverage, you may have to pay a higher premium.

Coverage outside the United States is not an option for surgery.  Even while traveling for pleasure Medicare will not cover and you need to have a supplemental insurance plan specifically that will cover all costs abroad or seek out a temporary insurance option.

Medicare provides resources to the community for information and has the option to monitor your claims at Medicare.gov Please see page for instructions on how to make a Medicare.Gov account and monitor your payment history Website instructions

You can estimate reimbursement rates with the provider fee look up tool.  Please read instructions and you will have to have the CPT codes to locate the rates (*some fees are determined on a local coverage level and not accessible online).
Look Up Tool

Medicare versus Medicaid
Let's define Medicare insurance first as many are confused by Medicaid programs and believe they have Medicare Coverage.  

Medicaid is low income insurance administered by the state of residence and reimbursement comes from Federal health insurance for those with low income and can't afford to pay for insurance. The policies of Medicare for transgender surgeries are not provided under Medicaid as each state sets their own policies.

Medicare is for those who are 65+ years of age OR those who have a disability, receive SSDI payments, and have been on the program for 2 years (some are eligible for Medicare quicker due to severity of their conditions which would typically exempt them from transgender surgeries). There is also a program for Adult children who have been disabled before reaching 18 years of age. They do receive benefits based on the eligibility of a parent.

Standard Medicare has the typical Red, White, and Blue format shown to the left.  The start dates of A and B are shown on the card and you use it when the provider asks for your health care insurance cards.  If you have any other insurance you may have to show it in addition (gap/supplemental plans) or you have an advantage or Medicaid plan thats is managing your Medicare (which might provide a different card).

You can have both insurances! If your income is low enough and you are disabled or 65+ many Medicaid programs will help by paying the premiums for Medicare and help with the 20% exclusions that Medicare does not cover.

For those with Medicare and Medicaid, there is a lot of various policies on Medicaid and impossible to know how each state administers the  programs where both insurances are in place.  This is where it's your responsibility to find out how the Medicaid will work for you.  Some are going to pay what Medicare will not, others may not pay at all and call the surgeries cosmetic, or a policy may be in place for using only in-network physicians.  You will have to speak with the plan administrators of your Medicaid program to continue forward and understand fiscal  liability. It's impossible for us to know how Medicaid programs work when the policies are individually run by each state.  I will encourage all though not to accept "NO" and appeal any negative decisions with Medicaid. 


  1. UNDERSTANDING ABN'S

    Your providers may ask you to sign what is called an Advanced Beneficiary Notice waiver before surgery.  

    This has been fairly standard for all surgeons who are taking Medicare at this time. 
    The ABN lists the items or services that Medicare isn't expected to pay for, an estimate of the costs for the items and services, and the reasons why Medicare may not pay. The ABN gives you information to make an informed choice about whether or not to get items or services, understanding that you may have to accept responsibility for payment.You’ll be asked to choose an option box and sign the notice to say that you read and understood it. You must choose one of these options:

    Option 1: You want the items or services that may not be paid for by Medicare. Your provider or supplier may ask you to pay for them now, but you also want them to submit a claim to Medicare for the items or services. If Medicare denies payment, you’re responsible for paying, but, since a claim was submitted, you can appeal to Medicare.

    Option 2: You want the items or services that may not be paid for by Medicare, but you don’t want your provider or supplier to bill Medicare. You may be asked to pay for the items or services now, but because you request your provider or supplier to not submit a claim to Medicare, you can’t file an appeal.


    Option 3: You don’t want the items or services that may not be paid for by Medicare, and you aren’t responsible for any payments. A claim isn’t submitted to Medicare, and you can’t file an appeal.
    An ABN isn't an official denial of coverage by Medicare. You have the right to file an appeal if payment is denied when a claim is submitted.

    REMEMBER THAT IF YOU PAY CASH AND TRY TO SELF BILL MEDICARE, THERE IS NO GUARENTEE YOU WILL RECIEVE ANY REIMBURSEMENT!  MANY FACTORS IMPACT MEDICARE PAYING FOR A SERVICE AND WITHOUT KNOWING ALL THEIR RULES AND REGULATIONS .  THE CASE PRICE MANY SURGEONS CHARGE IS TYPICALLY SIGNIFICALLY MORE THEN MEDICARE REIMBURSEMENT RATES ARE!